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Bluecross Blueshield of Western New York Formulary 1 Please Bring This Guide with You the Next Time You Visit Your Doctor

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Bluecross Blueshield of Western New York Formulary 1 Please Bring This Guide with You the Next Time You Visit Your Doctor BlueCross BlueShield of Western New York Formulary 1 Please bring this guide with you the next time you visit your doctor. If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com. CRP2107_009678.1 MG009678A (Revise Date 07/01/2021) A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association. Inside front cover TABLE OF CONTENTS INTRODUCTION . iii UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK . iii USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS . iv Save Money on Your Prescription Drugs . iv Finding Medications in the Guide . v SECTION 1 — THERAPEUTIC DRUG CATEGORIES . 1 SECTION II — INDEX . 8 ii The BlueCross BlueShield of Western New York Formulary 1 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price. INTRODUCTION BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows: Key P = A step edit applies to this drug. Step therapy means that in order to receive the medication with a step edit, a preferred medication must be tried first. z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication. = Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. + = Access restricted to specialty pharmacy. Medications must be obtained through a specialty pharmacy. = Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA Preventive Drug List. iii USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS Many employers, benefit sponsors, and individuals may use the formulary to help manage the overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient medications. Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed formulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card. Save Money on Your Prescription Drugs Here’s what you can do to save money: 1. Bring this member guide to your doctor and review the cost-saving information below. 2. Ask your doctor whether a drug listed in this guide is right for you.* Tier 3 Tier 1 Tier 2 Lowest cost to you Highest cost to you The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage. Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan. Affordable Care Act (ACA) Preventive Drug List The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at $0. They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan documents to confirm if the ACA Preventive Drug List applies to you. We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on page iii. This list is reviewed periodically and is subject to change. The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care provider and require a valid prescription. * Some plan designs require that you use a Tier 1 generic drug if a generic is available. Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 1. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability. iv Contraceptive Coverage under New York Insurance Law Contraceptives (for members whose benefits align with contraceptive coverage requirements under New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives with a generic equivalent are covered at the copayment based on your plan design unless deemed medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on the prescription in order for the brand-name contraceptive with a generic equivalent to be considered medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC) products are covered only when prescribed by a licensed health care provider and require a valid prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan. Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide for specific product examples. Finding Medications in the Guide This guide lists medications two different ways: Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis) Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair). Section 2: Alphabetically by drug name. Use this list to find your drug. Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the BlueCross BlueShield of Western New York Formulary 1. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com. v SECTION I — THERAPEUTIC DRUG CATEGORIES TIER TIER TIER TIER z Allergy/Cough & Cold z tolterodine ER 1 Cancer Drugs Ayvakit 3 z z trospium 1 Balversa 3 Antihistamines & Decongestants z Alkylating Agents z Braftovi 3 brompheniramine/phenylephrine 1 trospium ER 1 cyclophosphamide 1 z z Brukinsa 3 brompheniramine/pseudoephedrine 1 Myrbetriq 2 Alkeran 2 z z Calquence 3 z carbinoxamine 1 Toviaz 2 CeeNu 2 P z z Copiktra 3 cetirizine 1 P Detrol 3 Emcyt 2 z + z Daurismo 3 clemastine 1 P Detrol LA 3 Hexalen 2 z + z Erleada 3 cyproheptadine 1 P Ditropan XL 3 Leukeran 2 z Fotivda 3 dexchlorpheniramine 1 P Enablex 3 Myleran 2 z Gavreto 3 diphenhydramine 1 P Gelnique 3 Antimetabolites z + Gleevec 3 hydroxyzine HCl 1 z Oxytrol 3 + capecitabine 1 zP P + Idhifa 3 hydroxyzine pamoate 1 z Sanctura 3 mercaptopurine 1 z P + Inrebic 3 z levocetirizine 1 z Sanctura XR 3 methotrexate 1 z P + Kesimpta 3 loratadine 1 Cholinergic Agents Purixan 2 z + Kisqali 3 Urecholine 3 + z Inqovi 3 zP loratadine-D 1 + Kisqali Femara Co-Pack 3 + Onureg 3 z pseudoephedrine 1 Miscellaneous Koselugo 3 Trexall 3 z Semprex-D 2 z Gemtesa 3 + Lorbrena 3 z P z Xatmep 3 z Clarinex-D 3 z Jynarque 3 Mektovi 3 Hormones z z desloratadine 3 + Nerlynx 3 Blood anastrozole 1 z z Grastek 3 Orgovyx 3 bicalutamide 1 z z Odactra 3 Anticoagulants/antithrombotics Pemazyre 3 exemestane 1 z z Oralair 3 anagrelide 1 + Piqray 3 flutamide 1 z z Palforzia 3 aspirin 81mg OTC 1 Qinlock 3 letrozole 1 z z Ragwitek 3 aspirin 325mg OTC 1 + Retevmo 3 leuprolide 1 z Expectorant & Cough Products aspirin/dipyridamole 1 + Rozlytrek 3 megestrol 1 z benzonatate 1 clopidogrel 1 + Rubraca 3 z raloxifene 1
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